Provider Demographics
NPI:1093985517
Name:DONNELLON, STEPHEN WALTER
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:WALTER
Last Name:DONNELLON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:STEPHEN
Other - Middle Name:
Other - Last Name:DONNELLON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:637 W 20TH AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-1837
Mailing Address - Country:US
Mailing Address - Phone:907-347-0239
Mailing Address - Fax:956-424-3535
Practice Address - Street 1:637 W 20TH AVE
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-1837
Practice Address - Country:US
Practice Address - Phone:907-347-0239
Practice Address - Fax:956-424-3535
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-12
Last Update Date:2023-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK126336225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist